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Showing posts with label Dana Centre. Show all posts
Showing posts with label Dana Centre. Show all posts
Thursday, January 17, 2013
Thursday, January 17, 2013
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Agonising, torturous, tender, stinging, stiff, thumping, raw, itchy, stabbing, dull, crippling. We have many words for pain, many ways of trying to put into words a sensation that seems to defy communication. Asking someone “how much does it hurt?” seems a simple question, but as I learned at the Dana Centre last night, there are innumerable physiological, psychological and even cultural factors to consider when you’re trying to work out just how much pain someone is in. Being able to accurately quantify pain is hugely important to medicine, allowing the correct prescription of analgesics and courses of treatment for chronic conditions.
The speakers last night at the Dana Centre came from a variety of medical backgrounds, and all are trying to understand different aspects of pain. Our facilitator was the charmingly pleasant Tim Crocker-Buque, a junior doctor working in Accident and Emergency at the Royal London Hospital, and the rest of the panel was composed of Matthew Howard, a research scientist from the Department of Neuroimaging at Kings College London; Archie Naughton, a patient liaison representative speaking about his personal experience with pain; Melvin Muzue an Oxford DPhil student researching advanced magnetic resonance imaging of the brain; and Becky Saul, a lecturer-practitioner in paediatric pain at Great Ormond Street Hospital.
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| The Pain! |
It’s useful before we begin to pin down exactly what pain is. Tim Crocker-Buque quotes from the International Association for the Study of Pain Subcommittee on Taxonomy, 1986, telling us:
“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
It’s an elegant, precise definition, consciously clinical and antiseptic in its language. Accurate it may be, it begins to seem a little cold when Tim begins to tell us about some of the patients he’s seen in Accident and Emergency over the last week. People in excruciating pain from kidney stones, back pains rendering people unable to move, rugby players with dislocated joints and most memorably someone who had drunkenly fallen out of a window and impaled their thigh on a fence. I suspect if you asked any of these people if they were having an ‘unpleasant sensory experience’ you’d get the dirtiest of dirty looks from them.
Trying to get accurate information out of people that are in pain is tricky at the best of times, if they’ve just suffered a serious accident then they’re likely be in a heightened emotional state. Even if you are totally calm, it can still be frustratingly difficult to translate the exact kind of pain you’re in to a medical professional. Later in the evening an audience member makes a good point that even if you do explain yourself well, how you know whether the doctor or nurse has really understood what you’re talking about?
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| A classical 1-10 scale |
Traditionally, a 1-10 scale as shown above is used to allow patients communicate their pain. It’s easy to administer and understand, but also a rather fuzzy and subjectivel. The problems with it range from assuming numeracy in patients, the ability of the patient to communicate, the emotional state of the patient, and even, fascinatingly, their cultural background. We’re told how patients from Mediterranean backgrounds will happily and extensively describe exactly how and where their pain hurts, while those from Eastern European backgrounds tend to be taciturn and stoic, declining analgesics or even refusing to admit that they are in pain.
We’re told repeatedly that one of the primary roles of medical professionals is to relieve pain as soon as possible. When someone comes into A&E in crippling pain, very quickly they’ll be administered analgesics. I was surprised how readily doctors were willing to administer drugs like morphine to A&E patients, but on reflection they may well have to wait for a period before their injury can be treated. Personally I’d much rather be in a waiting room full of doped up and dozy injured people rather than on where the air is filled with agonised shrieks.
Quickly knowing what kinds of analgesics to administer becomes very important, and underlines the importance of accurate diagnostic tools. We’re talked through the ‘Wong-Baker faces’ pain rating scale. These cartoon faces are an excellent way for children to convey the amount of pain they’re experiencing in a way that eschews language or numeracy. The scale is flexible enough to allow for children to communicate the levels of emotional pain they feel too, Becky Saul shows us a pretty heartbreaking example of the Wong-Baker scale coloured in by a child at Great Ormond Street, where the most extreme pain is described as equivalent to when his father goes away on an extended business trip. While these faces are an excellent tool, and are elastic enough to be useful in understanding pain at the opposite end of the age scale in the elderly, it is still subjective, relying on the patients ability to communicate.
The pipe dream of many of the medics here is having an objective way of measuring pain. There are extremely accurate ways of measuring lots of physiological functions, we’re told how someone can have a sensor placed on their finger that shows precise blood oxygen levels. The patient can be administered an oxygen feed, and you can view in real time the numbers moving towards a safe level. The fantasy equivalent for this with pain, as Tim put it, would be a sensor you could slap onto someone’s head that would authoritatively tell them that the person is experiencing a pain level of, say, 7.8. Treatment could then be administered, and the doctors could watch the numbers fall.
This is currently science fiction, the closest realistic version being found in neuroimaging research using MRI machines that let us see how the human brain functions when the patient is experiencing pain. Blood has the useful property of being magnetic due to the presence of iron in haemoglobin. This allows us to see which areas of the brain ‘light up’ with increased blood flow during a painful experience. Much research into this in the 20th century was focussed on trying to identify a ‘pain centre’ in the brain. The existence of a single part of the brain that governs pain is a sensible prediction to make; senses like vision and hearing only stimulate certain areas. But as the MRI researchers on the panel tonight explained, physical suffering activates many different areas of the brain – what is referred to as a ‘pain matrix’.
That we are on the cusp of being able to objectively say whether a patient is in pain or not raises some tricky ethical issues. What do you do if the situation arises where a patient insists they’re in agony and yet an MRI shows no signs of it? Is it right to ever assume they’re lying? Similarly, what do you do if someone claims to be perfectly fine, and yet their brain scan shows the ‘pain matrix’ lighting up? At the moment these are hypothetical problems, but soon enough they won’t be, and the medical profession will have to wrestle with some pretty tricky dilemmas.
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| The 'Pain Matrix' |
Even if you could objectively detect pain within a patient, you still have to treat it. It's underlined that there's many factors that affect pain. These range from the context the pain is felt in to the emotional state of the patient and their cognitive abilities. Apparently, if a patient is depressed, they will tend to experience higher levels of pain than if they were happy. Excitement or danger can also influence the sensation of pain, if someone is pumped full of adrenaline then even the pain from a sudden massively traumatic injury like a lost limb can be temporarily suppressed.
This exploitation of the patient’s state of mind, getting them to focus on something other than the pain seems to be very useful. In Great Ormond Street, when an injured child is brought in by helicopter they’re quite rightly often terrified of what’s going on around them. The best tactic to calm them down is, apparently to give them an iPad to use, presumably a few sessions of ‘Angry Birds’ doing an awful lot to provide a familiar distraction for a traumatised child.
Conscious and unconscious mental exercises designed to relieve or suppress pain aren’t fully understood, but they seem an excellent unobtrusive way to work with chronic pain. Our speaker from the patient’s perspective, Archie Naughton, lost his lower leg in a car accident in 1976. He’s suffered phantom pain, sensations that the body perceives as coming from the missing limb. He describes these as being equivalent to someone cutting through his flesh with a rusty knife. This is a classic example of pain being experienced with no obvious physiological cause. So if there is nothing ‘wrong’ with Archie, how can this pain be relieved?
He tells us about his mental exercises to diminish the pain, ‘forcing’ it into another part of his body and telling himself not to worry about it. It’s an admirable example of the brain’s ability to consciously repress neurological signals. Exercises like this are fantastically useful, especially as Naughton has had bad experiences with painkillers in the past. He tells us of his unpleasant experiences with Tramadol, which he was prescribed after suffering from kidney stones. The notion of having to weigh up which is more important, pain relief or undergoing unpredictable and unpleasant mood and personality changes is a difficult one, to say nothing of the prospect of quickly developing a physical dependency on painkillers.
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| A cartoon illustrating common sensations of phantom pain. From 'A Gimp's Guide to the 801' |
Pain is the root cause of some of the most insidious misery a human being can go through. If depression is linked to pain then it seems to me to inevitably lead to a pretty horrible spiral. You feel depressed, so you feel pain, which makes you more depressed and so on. If you see nothing in the future but chronic pain, with no relief in sight then it’s not surprising that many sufferers commit suicide.
Conversely, pain is a sensation that keeps you alive. It’s a warning signal that something is wrong with you, an affirmation of life. There’s a genetic condition called congenital analgesia where the sufferer does not feel physical pain. These people do not tend to live very long, commonly biting off their tongues, breaking bones and not being able to detect pain from severe diseases, delaying treatment. So next time you stub your toe and dance around angrily berating the sky, take a moment afterwards to appreciate the fact that you can feel it.
When it comes to really understanding the ethics of treating pain, I like this 1968 quote from Margo McCaffery, pioneer in pain management:
“Pain is whatever the experiencing person says it is, existing whenever and wherever the person says it does.”
Even though we may not understand the causes, mechanisms or psychology of why someone is feeling pain, it doesn’t make that person’s individual pain any less valid. With this in mind, the intelligence, good humour and strong sense of empathy with their patients that I saw from the speakers tonight is immensely heartening.
Thanks to everyone who organised this at the Dana Centre, and please let me know if I’ve made any factual errors in the comments.
Wednesday, June 20, 2012
Wednesday, June 20, 2012
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| Palaces by Gina Czarnecki |
They must put something in the water at the Dana Centre, I always walk out of there feeling much smarter than when I walked in. Everything in the building seems to be geared towards intelligent discussion and learning. I sit down as an uninformed mug and when I've gotten up a few hours later I've got a head full of cutting edge scientific ideas and philosophy, and they manage to do all this without condescending or talking down to their audience! The people that tend to go there seem to be pretty switched on and forwarding thinking, consisting of a nice mix of science students and curious members of the public.
Tonight’s discussion revolved around the ethics of using human bodies and body parts in art and science. The focus of the debate was the sculpture ‘Palaces’ by Gina Czarnecki which is created using donations of milk teeth, but discussion covered a wide range of interesting topics including what we would like our bodies used for after death, the ‘ick’ factor and differing cultural values concerning the dead as well as many others. The only minor criticism I’d have of the night is that we didn’t get a chance to see the piece of art we were debating, I suppose I should have done my research and visited it beforehand, but all we had to go on were some rather small pictures to look at.
The room was unfortunately sparsely populated due to the fact that there was an England football game on that evening, so I was invited to take a seat at the ‘Talkaoke Table’. It’s an impressive doughnut shaped underlit thing, and it does a great job of promoting debate. Sitting at the table you feel a little self-conscious. For one, you’re being filmed and projected onto a video screen on two walls, and at any point you run the risk of having a microphone handed to you for your opinion. It is a great leveller, and gives as much priority and importance to the Professor of Cardiac Pharmacology at Imperial College (Sian Harding) as it does to some bozo off the street (me).
The experts at the debate were all singularly well informed on their subjects whilst also being very friendly and accommodating. They were, Gina Czarnecki, artist, Sara Rankin, Professor of Leukocyte and Stem Cell Biology at Imperial College, the above mentioned Sian Harding, and Hannah Redler, Head of Arts Projects at the Science Museum. Chairing the debate was Mikey Weinkove, who sat in the centre of the ‘doughnut’ and hosted proceedings.
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| 'For the Love of God' by Damien Hirst |
Initially, I had assumed that using human body parts in art was a recent development. The current defining image of Damien Hirst (the most successful contemporary artist) is a diamond encrusted platinum cast human skull with the original teeth, Marc Quinn’s ‘Self’ also attracted significant publicity as well as Gunter von Hagen's ‘Bodyworlds’ touring exhibition. However, as I realised last night, there is a rich historical tradition of using parts of the human body for artistic and religious reasons.
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| 'Self' by Marc Quinn |
On one hand it is fairly common in history for human body parts to be used as sacred objects; the various body parts of Saints being preserved in medieval reliquaries; the Saxon practice of making amulets from milk teeth to mark passage into adulthood. In another, the human body is used purely as an ingredient, as in the paint pigment ‘Mummy brown’ (favoured by the pre-Raphaelites) which was composed of ground up Egyptian mummies.
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| 'Morgan Le Fay' by Frederick Sandys (made with ground up dead people, folks!) |
It is an interesting thought experiment to ponder your own feelings about your body being used for art. There is a strange disconnection that comes from thinking of your body as a source of art materials, or as spare parts. It seems a little morbid to imagine bits of yourself on display in an art gallery. Even though I'm of the belief that once my number comes up, that’s it for me consciousnesswise the thought of how my body will ultimately wind up still occasionally nags at me. The pragmatic answer to this nagging feeling is that no matter what my preferences are on what will happen to me once I’m dead it will be for others to decide what will happen to my body (and I won’t care anyway, as I’ll be dead).
Even so, we like to tell ourselves that we’ll have a say in how we will be used after death, but frequently the wishes of the dead are over-ridden. For example, someone donating their body to medical science in the belief that their death will advance medical science might end up being used for close-range ballistics tests or to find out the effectiveness of a new type of landmine. Sometimes, even if the explicit wishes of the dead are made public, they will be ignored. A prime candidate for this is the skeleton of Charles Byrne, the ‘Irish Giant’ who stood 7’7” tall and is currently on display in the Hunterian anatomy museum in Lincoln’s Inn Fields. He died in 1783 and, seemingly mindful of the greedy eyes of contemporary curiosity collectors, requested to be buried at sea. Almost immediately upon his death his wards were bribed by anatomist John Hunter, the body was seized and put on public display where it has remained ever since. Today, scientists now feel that we have gotten all possible scientific insights from his body, and that we should finally respect the 230 year old wishes of the deceased and bury him at sea.
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| Skeleton of Charles Byrne - notably not buried at sea |
Complying with his wishes opens a rather complicated can of worms though. There are human remains on display in many museums in London that have been transplanted from around the world. A vast educational resource would be lost if we were to respect the wishes of these long-dead people. It is notable that the British Museum has already repatriated thousand year old aboriginal remains to Tasmania in accordance with the wishes of their descendants. So there is a lot of debate as to where to strike an ethical balance on whether human remains are on display for entertainment or education reasons.
So what about consent in the modern day? It is hardly unusual for people to request that their bodies be donated to science, but should this also cover them being used for artistic reasons? There was discussion as to whether there should be a separate donor card explaining that you’d like your body to be donated to ‘art’ after you’ve died. I think that this is a bad idea and just throws up an unnecessary level of confusion during the short window in which a body is viable as a source for donated organs. However there has been some controversy when artists have appropriated human tissue for their works using bodies donated on the basis that they’d be used for scientific research. The American artist Andrew Krasnow has exhibited a sculpture of a heart made from human skin sourced from bodies donated to science. Is it ethical to use a part of someone in this way? Would it cause unnecessary distress to friends and family of the deceased to learn that a visible part of their loved one was on display in a gallery somewhere?
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| 'Hollow Muscle' by Andrew Krasnow |
Also mentioned in debate about the source of human bodies and parts was Gunter von Hagens' ‘Bodyworlds’ exhibition. It was said during the debate that the bodies exhibited were those of Chinese prisoners, which did strike as particularly unethical, particularly if they were the bodies of political dissidents. I was relieved to find out later on after doing some research that this was not the case, and that this claim was the subject of a successful libel claim against ‘Der Spiegel’ by von Hagens. It seems that rather than having to depend on somewhat shady means, that they’re over-applied for candidates for plastination. Apparently there have been over 9000 bodies pledged specifically to the project by the public, a pretty astonishing turnout.
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| From 'Bodyworlds' by Gunter von Hagens |
The issue of consent was discussed in detail in relation to ‘Palaces’ and obtaining enough milk teeth from children to use as building material. I examined the leaflet distributed to children that lets them send their milk teeth to the team, and it implores children to help the tooth fairy construct her palace. This, while being almost entirely harmless, is still ultimately a lie, and the project hinges on the artist getting the consent of parents to lie to their children in order to gain their unwanted body parts. It’s a complicated ethical situation, but one that I think in this case has been neatly handled. It was mentioned that uptake has not been as high as they were hoping – they have only collected about 900 teeth (although this seems like a lot to me) and are still hoping for much more.
I think that these opinions on what they you’d like to happen to your body exist as a comforting feeling prior to death. Believing that your body will go on to benefit the future of mankind can provide some solace, and help avoid feelings that your life is, in the grand scale of things, pretty meaningless. Our bodies being recycled into art, science and medicine confers upon us a kind of immortality. It’s this feeling of continuity with the past and the future that is an important psychological crutch that helps us (and particularly helps those for whom death is an immediate concern).
If we begin to ignore the wishes of the dead, then this weakens the psychological value of that comforting idea. If a person soon to die knows that a friend specifically wished that all of their organs be donated, or that their body be donated to be used in a piece of art and those wishes were overridden upon their death then why should they bother making post-mortem plans for themselves? Conversely, once a person is dead then their body is no longer their own. If someone wished in their will that their body be donated to Gunter von Hagens, and their family found the idea distressing then I think the wishes of those still living should supersede those of the dead.
The majority of us in developed nations live in a sanitised, somewhat antiseptic world. We are generally not confronted with blood, sewage and gore on a daily basis. Society has developed complicated systems to separate us from these ‘disgusting’ things. A Londoner 300 years ago would think nothing of dumping their waste in the unpaved streets, and butchers would slaughter animals in the back of their shops, disposing of the entrails as best they could. The majority of us are a few steps removed from that now. Sewerage systems whisk our waste away from us at the push of a button, and the shrinkwrapped meat sold in supermarkets is rarely associated with an actual living animal. The use of human bodies and body parts in art serves to remind us of the pumping, living messy machinery of life that lies under our skin and our streets. It forces us to confront an idea of ourselves as physical creatures of bone and muscle rather than as the illuminated intellectual beings we would like to imagine ourselves as. What I took away from this debate was a view of the human body as a structure, as a source of raw materials and as an inescapably physical object, anchoring us to the world around us, and to each other.
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